Provider Demographics
NPI:1508847633
Name:ROUW, GREGORY R (DPM)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:R
Last Name:ROUW
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2025 STEARNS WAY
Mailing Address - Street 2:#105
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-4491
Mailing Address - Country:US
Mailing Address - Phone:320-252-2963
Mailing Address - Fax:320-252-4206
Practice Address - Street 1:2025 STEARNS WAY
Practice Address - Street 2:#105
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-4491
Practice Address - Country:US
Practice Address - Phone:320-252-2963
Practice Address - Fax:320-252-4206
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN486213ES0131X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN024325600Medicaid
MN024325600Medicaid
MN489000066Medicare ID - Type Unspecified